Background
Any patient presenting to the ED with new onset (grade II/III) ascites, worsening ascites, suspected sepsis, and/or any complication of cirrhosis should have a diagnostic tap performed as soon as possible.
Ultrasonography may be used by those competent/trained to do so.
Investigations
Ascitic fluid sent for:
- Differential Cell Count (EDTA (FBC) bottle)
- C&S (Blood culture bottles), cytology
- Albumin and Amylase (universal container)
SAAG gradient >11g/L indicates ascites is due to portal ⇑.
Management
Diuretics
Spironolactone commenced at 100mg/day, once daily dosing (up to a maximum dose of 400mg/day) and Furosemide at 40mg/day (up to a max of 160mg) with daily weights to achieve 0.5kg/day weight loss in patients without oedema, and 1kg/day weight loss in patients with oedema. Monitor U&Es daily.
Diuretics should be discontinued if severe hyponatraemia (serum sodium <125mmol/L), AKI, worsening hepatic encephalopathy, or incapacitating muscle cramps develop.
Request Dietetic input for low salt diet. Note very low salt diet increases diuretic complications.
Ultrasound
US Abdomen with Doppler portal vein.
Paracentesis
Therapeutic large volume paracentesis with albumin replacement: (usually performed in patients either resistant to maximal doses of diuretics or intolerant due to side effects, and in patients who become symptomatic or uncomfortable due to ascites).
- Maximum volume to be drained 15L
- For every 2.5L drained infuse 100mls of 20% albumin
- Albumin is requested on blood requisition form and charted on CUH Blood Component/Product Prescription and Transfusion Record – each unit (100 ml) should be given over 20-30 minutes
Note:
- No need to clamp drain as long as albumin being replaced
- Albumin replacement does not depend on albumin level
- Drain usually removed after 6 hour due to risk of secondary bacterial peritonitis
- After removal of drain, if still leaking, apply stoma bag to site (for 48 hours usually) – will stop spontaneously. Sutures may occasionally be required thereafter to prevent infection
- In patients with ascites who are hypotensive and/or hypovolaemic hyponatraemic – use 5% albumin as fluid replacement of choice. Normal saline/Hartmann's, when used as fluid replacement may worsen ascites
Spontaneous bacterial peritonitis (SBP)
Symptoms are often vague, hence very early diagnostic paracentesis is essential.
Diagnose if paracentesis demonstrates Neutrophils >250 cells/mm3.
Usual causative agents are gram negative bacteria (e.g. E.coli), and gram positive cocci (streptococci/enterococci).
Treatment
Broad spectrum antibiotics (typically Ceftriaxone or Pip-Taz) & Albumin: 1.5g albumin/kg (max 100g Albumin) in the initial six hours, followed by 1g/kg on day 3.
Patients recovering from one episode of SBP: secondary prophylaxis may be considered: typically Norfloxacin (Ciprofloxacin used as alternative), Co-Trimoxazole, or in certain instances, Rifaximin.